What is the treatment for ischial bursitis?

Treatment for Ischial Bursitis

The treatment for ischial bursitis should begin with conservative measures including activity modification, NSAIDs, and physical therapy, with corticosteroid injections reserved for refractory cases and surgical excision considered only when all other treatments have failed.

Initial Conservative Management

Activity Modification and Rest

• Avoid direct pressure on the ischial tuberosity
• Limit activities that aggravate symptoms (prolonged sitting, cycling)
• Use cushioning devices when sitting (donut cushions or foam padding)
• Relative rest from aggravating activities for 2-4 weeks

Pain Management

• NSAIDs are recommended as first-line medication for pain and inflammation 1
• Acetaminophen can be used as an alternative for those who cannot tolerate NSAIDs
• Apply ice through a wet towel for 10-15 minutes several times daily to reduce inflammation

Physical Therapy

• Stretching exercises for hamstrings and gluteal muscles
• Strengthening of core and hip muscles to improve biomechanics
• Manual therapy techniques to address soft tissue restrictions
• Ultrasound therapy may provide additional pain relief

Advanced Interventions for Refractory Cases

Corticosteroid Injections

• Consider when symptoms persist despite 4-6 weeks of conservative management 2
• Fluoroscopically guided injections provide significantly better pain relief (86.25%) compared to landmark-based injections (55%) 3
• Caution: Limit number of injections to avoid tissue atrophy and tendon weakening

Surgical Management

• Reserved for cases refractory to conservative treatment and injections
• Surgical excision of the bursa should be considered when all other treatments fail 4
• Outcomes after surgical excision are generally favorable with resolution of symptoms within an average of 21.6 days 4
• Patients typically achieve excellent clinical scores post-surgery (VAS score 0.7, Harris hip score 98.1 at one month)

Special Considerations

Inflammatory Conditions

• Patients with underlying inflammatory diseases have significantly poorer response to conservative treatment (66.7% non-response rate vs 10.3% in those without inflammatory disease) 5
• More aggressive management may be needed earlier in these patients

Infection

• If septic bursitis is suspected (fever, erythema, warmth), aspiration for culture and sensitivity should be performed
• Oral antibiotics should be administered for confirmed septic bursitis 2

Treatment Algorithm

1. First-line (0-4 weeks):

   • Activity modification and cushioning devices
   • NSAIDs or acetaminophen
   • Ice therapy
   • Initial physical therapy

2. Second-line (4-8 weeks if inadequate response):

   • Continue first-line treatments
   • Consider corticosteroid injection (preferably fluoroscopically guided)
   • Advanced physical therapy with focus on biomechanical correction

3. Third-line (>8 weeks with continued symptoms):

   • Repeat corticosteroid injection if first provided temporary relief
   • Consider surgical consultation for bursa excision if symptoms are severe and debilitating

4. For patients with inflammatory diseases:

   • Consider earlier progression to injections (at 2-3 weeks)
   • More vigilant monitoring for treatment response

The majority of patients (79.7%) respond well to conservative management, with only 17.2% requiring injections and 3.1% needing surgical intervention 5. Early identification of patients with inflammatory conditions is important as they are more likely to have chronic progression and poor response to conservative treatment.